Health inspection·October 10, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 10/09/24 at 1:37 P.M. with Registered Nurse (RN) #235 verified there was no comprehensive care plan in place for incontinence care for Resident #77. RN #235 stated Resident #77 had been incontinent of bowel and bladder since admission and should have had a care plan for incontinence care since the initiation of her comprehensive care plan. Review of the facility policy titled Good [NAME] Home Comprehensive Care Plans, dated 09/2024 revealed the facility will develop and implement a comprehensive person-centered care plan for each resident. The comprehensive care plan will be developed with seven day after the completion of the comprehensive MDS assessment. Event ID: Facility ID: 365963 If continuation sheet Page 2 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Home 725 Columbus Ave Fostoria, OH 44830 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interview, and review of the facility policy, the facility failed to provide showers timely to residents who were dependent on staff for showers/bathing. This affected one (Resident #8) of three residents reviewed for activities of daily living (ADL). The facility census was 83. Residents Affected - Few Findings include: Review of Resident #8's medical record revealed an admission date of 03/17/23. Diagnosis included severe sepsis without shock, chronic obstructive pulmonary disease, and congestive heart failure. Review of Resident #8's quarterly Minimum Data Set assessment dated [DATE] revealed the resident had a moderate cognitive impairment. Resident #8 required substantial assistance from staff for showers, baths, and personal hygiene. Review of Resident #8's care plan revealed she had an ADL self-care self-care performance deficit related to activity intolerance, impaired gait and balance, limited mobility, musculoskeletal impairment, and neuropathy, Interventions included the resident required substantial assistance from staff with bathing and showering. Review of Resident #8's shower schedule revealed showers were scheduled every Tuesday and Friday. Review of Resident #8's shower documentation dated August 2024 through 10/07/24 revealed Resident #8 did not receive four scheduled showers between 09/03/24 through 09/13/24. Review of Resident #8's nurses notes revealed no documentation of why the showers were missing. Interview with Resident #8 on 10/07/24 at 10:25 A.M. revealed she wished to receive showers timely but the staff failed to assist her regularly. Interview with Licensed Practical Nurse (LPN) #433 on 10/08/24 at 1:01 P.M. verified Resident #8 failed to have showers completed timely between 09/03/24 through 09/13/24 and the medical record was silent as to why. Review of the facility policy titled Good [NAME] Home Resident Showers dated 01/19/23 revealed it is the practice of the facility to assist residents with bathing to promote proper hygiene, stimulate circulation, and help prevent skin issues as per current standards of practice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365963 If continuation sheet Page 3 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Home 725 Columbus Ave Fostoria, OH 44830 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and record review, the facility failed to ensure wound prevention boots were in place as physician ordered and failed to obtain a resident's weekly weight as physician ordered. This affected one (Resident (#11) of one resident reviewed for wounds and 21 residents reviewed for physician orders. The facility census was 83. Residents Affected - Few Findings include: 1. Review of Resident #11's medical record revealed an admission date of 12/01/22. Diagnoses included cerebral vascular accident, diabetes mellitus, pressure induced deep tissue damage of right heel, and non-pressure chronic ulcer of right ankle with fat layer exposed. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11's cognition was intact. Resident #11 had an open lesion on his foot and required dressings to the feet. Review of the care plan revealed Resident #11 had altered skin integrity related to a right ankle vascular wound, right anterior third toe traumatic wound, and a left posterior ankle wound. Interventions included pressure relieving devices as ordered. Review of Resident #11's physician order dated 10/24/23 revealed an order for a heel lift boot to the right lower extremity every day and night shift. Observations of Resident #11 on 10/07/24 at 9:26 A.M. and 11:33 A.M., and 10/08/24 at 1:02 P.M. revealed Resident #11 was not wearing right heel lift boot. Interview with Resident #11 on 10/08/24 at 1:02 P.M. stated the facility staff did not apply the heel lift boot daily and he was unsure where the boot was located. Interview with the Wound Care Nurse Practitioner #600 on 10/10/24 at 11:58 A.M. stated the right lateral ankle wound was chronic and the main goal was to avoid infection. The wound had not worsened. Interview with Unit Manager (UM) #302 on 10/10/24 at 12:02 P.M. verified Resident #11 was not wearing his right heel boot lift as physician ordered. UM #302 stated she could not locate Resident #11's boot. Observation on 10/10/24 at 3:40 P.M. revealed Resident #11 was in his wheelchair and the heel lift boot was in place. 2. Review of Resident #54's medical record revealed an admission date of 03/26/24. Diagnosis included disease of the pericardium, vitamin deficiency, protein malnutrition, cystic fibrosis, and adult failure to thrive. Review of Resident #54's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a moderate cognitive function. Review of Resident #54's care plan revealed he required tube feeding related to dysphagia, adult failure to thrive, malnutrition, and weight loss. Goals included the resident will maintain adequate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365963 If continuation sheet Page 4 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Home 725 Columbus Ave Fostoria, OH 44830 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm nutritional and hydration status as evidenced by a weight stable and no signs of malnutrition. The resident received nothing by mouth and was provided nutrition via a feeding tube. Review of Resident #54's medical record dated 05/24/24 revealed a physician's order for weekly weights every night shift every Friday. Residents Affected - Few Review of Resident #54's weight record from 04/12/24 through 10/01/24 revealed the resident's weight were not obtained on the following dates: on 04/12/24, 04/26/24, 05/03/24, 05/17/24, 05/24/24, 05/31/24, 06/21/24, 06/28/24, 07/19/24, 07/26/24, 08/02/24, 08/16/24, and 09/06/24. Interview with the Director of Nursing (DON) on 10/10/24 at 8:18 A.M. verified Resident #54's weekly weight were not obtained as physician ordered. The DON verified Resident #54's weight was not obtained on 04/12/24, 04/26/24, 05/03/24, 05/17/24, 05/24/24, 05/31/24, 06/21/24, 06/28/24, 07/19/24, 07/26/24, 08/02/24, 08/16/24, and 09/06/24. Interview with the Clinical Operations Director #500 on 10/10/24 at 2:35 P.M. revealed the facility had no policy regarding following physician orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365963 If continuation sheet Page 5 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Home 725 Columbus Ave Fostoria, OH 44830 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on record review, observation, staff interview, and policy review, the facility failed to prepare pureed foods per the recipe and follow the dietician recommendations for serving sizes. This had the potential to affect six residents (#2, #37, #38, #46, #47, and #68) who received pureed meals and had to the potential to affect 77 residents who received regular or mechanical soft meals from the kitchen. The facility census was 83. Findings include: 1. Review of the Dining Manager's recipe for pureed vegetables revealed the recipe called for one quart of vegetables with one-fourth cup of melted margarine. Observation on 10/08/24 at 10:48 A.M. revealed Chef #282 was preparing the vegetable for the pureed diets. The chef placed the vegetables in the food processor then began pouring in a butter tasting substance used for grilling, sauteing, and pan frying. Chef #282 failed to measure the vegetables nor the butter substance. He poured at least one cup of butter substance in the food processor. Interview with Culinary Director #251 on 10/08/24 at 10:44 A.M. verified Chef #282 did not follow the Dietary Manager's recipe for pureed vegetables. 2. Review of the facility menu spreadsheet for the week of 10/07/24 revealed the residents should be served three four ounce meatballs per serving. Observation on 10/09/24 between 11:03 A.M. and 11:15 A.M. revealed Dietary Assistants #273 and #384 were plating spaghetti and meatballs. Dietary Assistants #273 and #384 were serving between three and six meatballs on the plates. Interview with Dietary Assistant #384 on 10/09/24 at 11:13 A.M. revealed he was unaware of the serving sizes and not necessarily following the facility's menu spreadsheet. Interview with Culinary Director #251 on 10/09/24 at 11:24 A.M. verified Dietary Assistants #273 and #384 were not serving the portion size of meatballs as stated in the facility's menu spreadsheet. Review of the facility's undated policy titled Good [NAME] Home Puree Food Preparation revealed each resident must receive and the facility must provide food that is prepared by methods that conserve nutritive value, flavor, and appearance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365963 If continuation sheet Page 6 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Home 725 Columbus Ave Fostoria, OH 44830 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and policy review, the facility failed to store foods properly in the refrigerator and failed to discard expired food items. This had the potential to affect all 83 residents who the facility identified received food from the kitchen. The facility census was 83. Findings include: 1. Observation of the main kitchen refrigerator on 10/07/24 at 8:10 A.M. revealed there was a container of thickened pudding dated 09/23/24 and a container of thickened juice dated 09/23/24 which were outdated and failed to be discarded. Observation of the walk in refrigerator on 10/07/24 at 8:23 A.M. revealed a box of sliced mushrooms were on a wire shelf and were open to air. The cardboard lid failed to be secured to the box. Interview with Culinary Director #251 on 10/07/24 at 8:25 A.M. verified the thickened pudding and thickened juice were outdated and not discarded and the mushrooms were not stored properly. 2. Observation of the pureed food preparation on 10/08/24 at 10:45 A.M. revealed Chef #282 was preparing pureed beef stroganoff. After placing the stroganoff in the food processor, he mixed hot water with beef base to use as the thinning agent. Observation of the beef base jar revealed it had a best if used by date of 08/22/24. Interview with Chef #282 and Culinary Director #251 on 10/07/24 at 10:47 A.M. verified the chef was utilizing the beef base past the expiration date. The beef stroganoff mixture was then discarded and a new mixture was prepared. Review of the facility policy titled Date Markings dated 11/2005 revealed the facility should discard all food past their used by date. Date marking is required for foods that are considered held under refrigeration for more than a cumulative total of 24 hours before service. If the food is maintained at a temperature of 41 degrees Fahrenheit or less, mark the foods use by date for seven calendar days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365963 If continuation sheet Page 7 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Home 725 Columbus Ave Fostoria, OH 44830 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, staff interview, facility policy, and review of the Centers of Disease Control and Prevention (CDC) guidance, the facility failed to ensure staff donned appropriate personal protective equipment (PPE) in COVID-19 positive resident's rooms. This had the potential to affect all nine (#48, #49, #65, #67, #73, #76, #82, #88, and #189) residents in the 200 hall who were not COVID-19 positive. In addition, the facility failed to ensure four (#1, #11, #54, and #79) residents with a wound or indwelling medical device had enhanced barrier precautions in place. The facility identified an additional nine (#17, #30, #45, #48, #52, #53, #55, #68, and #189) residents who required enhanced barrier precautions. Additionally, the facility failed to ensure hand hygiene prior to administering medications to Resident #14. The facility census was 83. Residents Affected - Some Findings include: 1. Review of the medical record revealed Resident #188 was admitted on [DATE]. Diagnoses included COVID-19 (10/03/24). Review of the social service progress note, dated 10/04/24, revealed Resident #188 had been diagnosed with COVID-19 and remained in isolation. Review of Resident #188's physician order, dated 10/08/24, revealed an order for a single room contact droplet isolation for ten days with all services brought to the resident in room. Observation on 10/07/24 at 11:34 A.M. revealed Registered Nurse (RN) #213 was in Resident #188's room assisting the resident . RN #213 was wearing a N-95 mask over a surgical mask and gloves. RN #213 was not wearing a gown or eye protection. Interview on 10/07/24 at 11:40 A.M. with RN #213 verified she was not wearing eye protection and a gown. RN #213 verified she was assisting Resident #188 with care as he needed assistance. RN #213 stated there was no gown in the PPE cart. 2. Review of the medical record revealed Resident #30 was initially admitted on [DATE]. Diagnoses included COVID-19 (09/29/24). Review of the Minimum Data Set (MDS) assessment, dated 08/09/24, revealed Resident #30 was cognitively intact. Review of Resident #30's physician orders, dated 09/29/24 to 10/09/24 revealed an order for single room contact/droplet isolation for ten days with all services brought into the resident room. Observation on 10/07/24 at 11:52 A.M. revealed Registered Nurse (RN) #235 entered Resident #30's room. RN #235 donned a N-95 mask placed over the surgical mask and no eye protection in place prior to entering the resident's room. Interview on 10/07/24 at 12:07 P.M. with RN #235 verified Resident #30 was COVID-19 positive. RN #235 verified the N-95 mask was placed over the surgical mask and no eye protection was worn. RN #235 stated the resident was not coughing or spewing saliva; therefore the eye protection was not necessary. Observation on 10/08/24 at 2:30 P.M. revealed State Tested Nursing Assistant (STNA) #338 entered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365963 If continuation sheet Page 8 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Home 725 Columbus Ave Fostoria, OH 44830 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #30's room after donning gloves, a N95 mask over a surgical mask, and a gown. No eye protection was worn in the resident's room. Interview on 10/08/24 at 2:36 P.M. with STNA #338 verified a N-95 mask was donned over the surgical mask and no eye protection was worn. STNA #338 stated there was no eye protection available in the PPE cart outside Resident #30's room. Review of CDC's guidance titled Infection Control Guidance: SARS-CoV-2, found at https://www.cdc.gov/covid/hcp/infection-control/?CDC_AAref_Val=https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection dated 06/24/24 revealed healthcare professionals who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a N-95 mask or higher, gloves, gowns, and eye protection. Review of CDC's guidance titled How to Use your N95 Mask Respirator, found at https://www.cdc.gov/niosh/topics/publicppe/use.html#:~:text=Place%20the%20N95%20respirator%20under,Do%20not%20 dated 05/16/23, revealed N95 respirators must form a seal to the face to work properly. This is especially important for people at increased risk for severe disease. 3. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE]. Diagnosis included pressure induced deep tissue damage of right heel, and non-pressure chronic ulcer of right ankle with fat layer exposed. Review of Resident #11's annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had an open lesion on his foot and required dressings to the feet. Review of the medical record revealed Resident #54 was admitted on [DATE]. Diagnoses included protein malnutrition, adult failure to thrive, and dysphagia. Review of the most recent care plan revealed Resident #54 required tube feeding due to dysphasia, adult failure to thrive, malnutrition, and weight loss. Review of the medical record revealed Resident #1 was admitted on [DATE]. Review of the MDS assessment, dated 09/20/24, revealed Resident #1 had a feeding tube. Review of the medical record revealed Resident #79 was admitted to the facility on [DATE]. Diagnoses included retention of urine and neuromuscular dysfunction of bladder. Review of the MDS assessment, dated 09/16/24, revealed Resident #79 had an indwelling catheter. Observations on 10/08/24 at 4:10 P.M. revealed Residents #1, #11, #54, and #79 did not have enhanced barrier precautions in place. Interview on 10/08/24 at 4:15 P.M. with State Tested Nursing Assistance (STNA) #341 verified when providing care to residents with a catheter or tube feed, gloves were worn but no additional PPE such as a gown have been donned. Interview on 10/08/24 at 4:22 P.M. with STNA #362 verified when providing care to residents with a catheter or tube feed, gloves were worn but no additional PPE such as a gown have been donned. Interview on 10/08/24 at 4:32 P.M. with the Director of Nursing (DON) verified no residents in the facility had enhanced barrier precautions in place. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365963 If continuation sheet Page 9 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365963 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Good Shepherd Home 725 Columbus Ave Fostoria, OH 44830 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the policy titled Enhanced Barrier Precautions, dated 2024, revealed an order for enhanced barrier precautions will be obtained for residents with any of the following: wounds (chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g. central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters) even if the resident is not known to be infected or colonized with MDRO (multidrug-resistant organisms). Review of the CDC guidance titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDRO), reviewed 07/12/22 and located at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html revealed enhanced barrier precautions apply to all residents with any of the following infections or colonization with MDRO (when contact precautions do not apply): wounds and/or indwelling medical devices (e.g. central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status. 4. Review of the medical record for Resident #14 revealed she was admitted on [DATE] with diagnoses of anxiety, cerebral vascular accident (CVA) (stroke), anemia, anxiety, thyrotoxicosis, gastroesophageal reflux disease (GERD), osteoarthritis, hypertension (HTN), chronic kidney disease (CKD), visual loss, and metabolic encephalopathy. Review of the current physician orders from 10/24 for Resident #14 revealed she was prescribed a acetaminophen 500 milligrams (mg), potassium chloride 10 milliequivalence (meq), metoprolol 12.5 mg (HTN), areds2 preservision (visual loss), amlodipine 10 mg, pantoprazole 40 mg (GERD), glucosamine chondroitin (osteoarthritis), folic acid 400 micrograms (mcg), Buspar 2.5 mg (anxiety), Plavix 75 mg (CVA), and iron supplement 325 mg (anemia). Observation on 10/09/24 at 8:07 A.M. during medication pass observation of Medication Aide (MA) #290 revealed she did not use hand hygiene prior to pulling the medications for administration for Resident #14. MA #190 removed metoprolol 25 mg from the pill bottle and broke the pill in half (for a dose of 12.5 mg as prescribed) and handled the medication without gloves and placed the other half of the pill back into the medication bottle. Further observation at 10/09/24 at 8:16 A.M. of MA #290 revealed to count the number of pills in the medication cup, MA #290 poured the entire cup of pills onto the top of medication cart without a barrier and picked up each pill to count without gloved hands and placed them back into the medication cup for administration. Interview on 10/09/24 at 8:18 A.M. with MA #290 verified she did not complete hand hygiene prior to preparing the medications for administration for Resident #14. MA #290 verified she broke the metoprolol in half without using gloves and poured pills directly onto the medication cart without a barrier and continued to touch the medication for Resident #14 with ungloved hands and then administered the medications to Resident #14. Review of the facility policy titled, Medication Administration Guidelines, dated 02/2019 revealed medications are to be administered per physician order to promote positive resident outcomes. Wash hands prior to handling medications, after administering medication, and after direct resident contact. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365963 If continuation sheet Page 10 of 10